Spotlights on Health and Rights

Key topics in the Heilbrunn Department of Population and Family Health

Reproductive Health

Hormonal Methods

Many hormonal birth control methods utilize a combination of hormones (i.e. synthetic estrogen and progestin). Other methods contain only one hormone (progestin).

Combination Hormonal Methods

Oral contraceptive pills (OCPs), the Ortho Evra Patch, and the NuvaRing prevent pregnancy by:

  • Preventing ovulation by blocking the LH surge;
  • Inhibiting sperm penetration by thickening the cervical mucous;
  • Delaying sperm transport; and
  • Limiting the sperm's ability to fertilize the egg.

Oral Contraceptive Pills

Method Use

  • The pill is taken daily at about the same time for 21 days, followed by a hormone-free period of seven days, during which a withdrawal bleed that resembles a menstrual period takes place (accompanied by either taking no pills or seven placebo pills).
  • Other options for use of birth control pills include taking two, three, or four consecutive cycles of 21 pills (up to 84 active pills) followed by one seven-day hormone free interval.
  • If more than one or two pills are missed, women should use a back-up method for the remainder of that pill pack and until they have ingested seven active pills in a row in order to remain protected from pregnancy.

Effectiveness

High (99.7% with perfect use).

Potential Benefits/Advantages

  • Not coitus dependent (i.e. does not need to be used at the time of intercourse).
  • Decreases dysmenorrhea (pain associated with menstruation), menstrual blood loss, and pre-menstrual symptoms.
  • Reduces incidence of ovarian cysts, benign breast conditions, pelvic inflammatory disease, uterine fibroids, and iron deficiency anemia.
  • Reduces risk of ectopic pregnancy,
  • Reduces risk of endometrial and ovarian cancer, although not of breast cancer.
  • May improve acne.

Disadvantages/Risks

  • Must be taken daily around the same time, so is not a good method for people who would have trouble doing that or don't want family members to know they are using birth control.
  • May be expensive for women who do not have insurance coverage for contraception or access to free or low cost services.
  • Provides no protection against sexually transmitted infections including HIV.
  • Cardiovascular events, i.e. heart disease, stroke, and venous thromboembolism (blood clots), although extremely rare, do occur at increased rates. Women with known risk factors for cardiovascular disease (such as smokers) are at increased risk.
  • Absolute contraindications (medical conditions precluding use of the method) include blood clotting disorders, heart disease, uncontrolled hypertension, severe migraine headaches, major surgery with prolonged immobilization, breast, endometrial or other estrogen related cancers.

Dual Method

Condoms should be used for first seven days for contraceptive protection, and on-going for STI/HIV prevention.

Warning Signs/Major Side Effects

Teaching the acronym "ACHES" is a "gold standard" of family planning education.

Warning signs that a woman may be developing the major side effects of birth control pills (rare cardiovascular complications) are:

A = Abdominal Pain

C = Chest Pain

H = Headaches (severe)

E = Eyes (i.e., blurred vision, loss of vision)

S = Severe leg pain (blood clot in the legs)

Minor Side Effects

Minor side effects of the birth control pill may include nausea, appetite changes, breast tenderness, and/or spotting or bleeding between menstrual periods. Although they usually resolve within one to three months, and do not pose health risks to women, minor side effects may result in method discontinuation.

Educational Messages

  1. Teaching women about the possibility of very common minor side effects when initiating the pill and other combination methods can help allay fear and increase compliance.
  2. Conditions that contraindicate the use of the pill and other hormonal birth control methods are not common in the majority of women of childbearing age. The risks of developing serious problems with hormonal method use are low. Yet, a survey conducted in 2000 revealed that 41% of women interviewed thought that the pill was associated with significant health hazards. Therefore, advising women on the relative safety and effectiveness of the pill and other hormonal methods of birth control is important.

Contraceptive Patch

Approved in 2002, the patch is a small adhesive strip that is applied to the skin (administered transdermally), permitting hormones to enter the bloodstream directly.

The effectiveness, mechanisms of action, advantages, disadvantages, major and minor side effects, warning signs, and dual methods are similar to the oral contraceptive pil.


Method Use

  • The patch is applied anywhere on the body except for the breasts, the palms of the hands, or the soles of the feet.
  • One patch is applied each week for three weeks on the same day, also called, "Patch Change Day."
  • During the fourth week, no patch is used (this is called the "patch-free week"). A withdrawal bleed usually occurs during the patch-free week.
  • Consider use of emergency contraception if patch is off for more than one or two days and unprotected sex occurs.

Additional Potential Benefits/Advantages

  • An important advantage of the patch is that the woman does not need to remember to take a pill each day.
  • Because hormones enter the bloodstream directly, bypassing breakdown in the liver, the possibility of gastrointestinal side effects (i.e. nausea and vomiting) is decreased.

Additional Disadvantages/Risks

  • Skin irritation at the site of placement is found in approximately 20% of patch users.
  • Less effective in women over 198 pounds.

Vaginal Ring

Approved in 2002, the NuvaRing is a soft, flexible ring that releases a low and steady amount of estrogen and progestin, which are absorbed into the blood stream through the vagina.

The effectiveness, mechanisms of action, advantages, disadvantages, major and minor side effects, warning signs, and dual methods are similar to the oral contraceptive pill.


Method Use

  • Use of the ring generally requires comfort with self-insertion.
  • The ring is inserted in the vagina but placement doesn't matter as long as it is secure. Because it is placed in the vagina, some people are confused and think it provides some type of physical barrier, which it does not.
  • Following insertion, the ring is left in place for three straight weeks, and removed after 21 days, to allow for a ring-free week when a withdrawal bleed usually occurs.
  • Consider use of a back-up method such as condoms or emergency contraception if ring is out of the vagina for more than three hours, or if the new ring is not re-inserted on time.
  • Here's a video about the insertion and use of NuvaRing.

Additional Potential Benefits/Advantages

After insertion, the woman does not need to remember to take a pill each day.

Progestin-Only Hormonal Contraceptives

Progestin-only methods provide options for women who cannot use estrogen, and for women who are breast-feeding.

Depo Provera, Noristerat, the mini-pill, Norplant, and Implanon prevent pregnancy by:

  • Inhibiting ovulation by suppressing FSH and LH, and eliminating the LH surge.
  • Thickening the cervical mucous and preventing sperm penetration.
  • Producing changes in the endometrial lining.

The Mirena I.U.D. ( see I.U.D. section, below) also contains progestin.

Depo Provera

(depot medroxyprogesterone acetate/DMPA)

Method Use

  • Usually injected within the first seven days of menstruation, though a quick start protocol is a more promising prevention strategy.
  • The woman returns for injection every 11-12 weeks (3 months).
  • Consider a back-up method such as condoms or emergency contraception if late for injection.

Effectiveness

Highly effective method of birth control (99.7% with perfect use).

Benefits/Advantages

  • Not coitus dependent.
  • Rare cardiovascular effects of methods containing estrogen have not been demonstrated.
  • Decreases dysmenorrhea and menstrual cramping.
  • Reduces risk of ectopic pregnancy, anemia, endometrial cancer, uterine cancer, and pelvic inflammatory disease (PID).
  • Safe option for breast-feeding women.
  • Does not affect fertility long-term.

Disadvantages/Risks

  • Delay of return to baseline fertility (average is about 10 months) may occur. However, pregnancy risk is immediate if re-injection is late.
  • Provides no protection against sexually transmitted infections including HIV.
  • Unpredictable menstrual patterns, including either increased spotting and bleeding or amenorrhea (absence of menstrual periods).
  • Weight gain.
  • Breast tenderness.
  • Decrease in bone density, which probably reverses upon discontinuation (further study of the long-term effects of Depo Provera on bone density, particularly in adolescents is needed).
  • Depression in individual women but not overall.
  • Inability to immediately discontinue method.
  • Rare allergic reactions.

Warning Signs/Major Side Effects

  • Repeated, very painful headaches
  • Heavy Bleeding
  • Depression
  • Severe lower abdominal pain
  • Pus or prolonged pain or bleeding at the injection side.

Minor Side Effects

  • Irregular bleeding patterns
  • Amenorrhea (loss of periods)

Dual Method

Condoms should be used for first seven days for contraceptive protection, and on-going for STI/HIV prevention.

Noristerat

Used primary in Latin America and Africa, Noristerat's effectiveness, mechanisms of action, advantages, disadvantages, major and minor side effects, warning signs, and dual methods are similar to Depo Provera.

Method Use

Injection every two months

Progestin Only Pills ("Mini-Pills")

The mechanisms of action, advantages, disadvantages, major and minor side effects, and warning signs, are similar to those of Depo Provera.

Mini-Pill Method of Use

  • Usually begins with menses, or post-partum while breast-feeding.
  • Take one pill daily at the same time. If three hours late for pill, back-up method is needed.
  • Consider a back up method such as condoms or emergency contraception for incorrect or inconsistent use.

Effectiveness

  • High (99% with perfect use)
  • Slightly less effective than combined hormonal pills

Additional Disadvantages/Risks

  • Very important that method be taken every day at the same time of day.
  • Expensive for women who do not have insurance coverage for contraception or access to free or low cost services.
  • Pregnancy is more likely than with the regular pill when pills are missed due to the low dosage.
  • Delayed period after several months after pill discontinuation may be a sign of pregnancy

Norplant and Implanon Implants

In the United States, the use of Norplant was discontinued in the late 1990's, but it is still used in over 60 countries. Implanon, a new progestin-only implant, is available in Europe and now the United States.

The mechanisms of action, advantages, disadvantages, major and minor side effects, and warning signs are similar to those of Depo Provera.

Method Use

  • Through a minor surgical procedure, six rod implants (Norplant) or one rod implant (Implanon) are implanted under the skin in the upper arm.
  • The rod implants release a daily dose of levonorgestrel.
  • Can be used for up to seven years.

Effectiveness

Very effective method (99.5% with perfect use).

Additional Disadvantages/Risks

Dependent on a medical provider for method removal, which can be a barrier if experienced providers are not readily available.